COVID-19-related disruptions in rheumatology care only partly offset by telehealth
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Rheumatology follow-up visit cancellations climbed to 60% during the height of the COVID-19 pandemic, and were more common for older, rural, Black and Hispanic patients, as well as those of lower socioeconomic status, according to data.
What’s more, that drop-off in in-person visits was only partially offset by telehealth — the use of which grew from near-nonexistence to more than 40% of all follow-ups at the pandemic’s height — with older, rural and poorer patients less likely to make the switch, the researchers wrote in Arthritis Care & Research.
“Telehealth, defined as the use of electronic information and telecommunications technologies to support long-distance clinical health care, offers an attractive alternative to face-to-face visits for at least a subset of patients, especially for those with an already-established diagnoses from their rheumatology provider,” Michael George, MD, MSCE, of the University of Pennsylvania, and colleagues wrote.
“Little is known, however, about the patterns of health care disruptions and telehealth use in rheumatology practices during the pandemic, or the degree to which vulnerable patient populations have been disproportionately affected,” they added.
To better understand the COVID-19 pandemic’s impact on rheumatology care, as well as the use of telehealth, within the context of a large community practice-based network, George and colleagues analyzed data from the Columbus electronic health record warehouse, via the American Arthritis and Rheumatology Associates (AARA) network. According to the researchers, the AARA network, and its business affiliate Bendcare, is the largest “super group” of rheumatology specialist providers in the United States, and includes approximately 300 full-time practicing rheumatology clinicians in 92 offices across 27 states.
These providers use a common EHR system featuring an embedded video-based telehealth platform. The EHR data also includes patient-reported outcome (PRO) information from the NIH PROMIS system, as well as linked laboratory, pharmacy and health plan claims data. For their study, George and colleagues examined trends in in-person visits compared with telehealth sessions and canceled appointments during three time periods — pre-pandemic, the transition during the pandemic, and the transition post-pandemic. The transition period during the pandemic was defined as the 6 weeks starting from March 23, 2020, while the post-pandemic transition was set at May 2020 to August 2020.
According to the researchers, there were 7,075 visits per week, among 60,002 unique rheumatology patients, during the pre-pandemic period. The number of in-person visits decreased by 24.6% during COVID-19 transition period, but later rebounded to pre‐pandemic levels during post‐pandemic transition. There were nearly no telehealth visits logged during the pre‐pandemic days. However, their prevalence grew substantially during the COVID-19 transition period, ultimately accounting for 41.4% of all follow‐up visits. They then slightly decreased to 27.7% of visits during the post‐pandemic transition.
Meanwhile, older patients, women and those who were Black, Hispanic, lived in rural areas or were of lower socioeconomic status, were associated with a greater likelihood of canceling follow-up appointments. Most factors were also associated with a lower likelihood of using telehealth compared with in‐office visits, the researchers wrote. Patients who lived farther away from the rheumatologists’ office were more likely to use telehealth.
“We observed large disruptions in care during the COVID-19 pandemic partially offset by telehealth use, with evidence that telehealth continues to be an important part of care delivery,” George and colleagues wrote. “Telehealth and other technology focused tools facilitating remote patient care and monitoring may be valuable to optimize outcomes, but these approaches need to be made more accessible, irrespective of the important social determinants of health that impact access to technology-enabled care.
“The substantial disparities we found in access to care for rheumatology patients during the pandemic based on age, socioeconomic status, and rural residence should be a call to action for rheumatology providers,” they added. “Vulnerable populations should be prioritized, with specific strategies developed to reduce disparities in access to rheumatology care and maximize health and quality of life for these patients.”
Perspective
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The use of telemedicine has been around for a number of years. This was initially started to allow access to medical care for patients in rural areas or in areas where access to specialty care was limited or not available.
Before the public health emergency of 2020, several states, including Alaska, Hawaii and Arkansas, allowed patients and their medical data to be seen, reviewed and acted upon by health care providers outside the state where the patient resided. In March of 2020, this availability was expanded to all U.S. states and territories due to the COVID-19 pandemic. Unfortunately, not all patients had access to these services, even in clinics and centers that were equipped to provide telemedical care. This created an interruption in care for many patients with rheumatic disorders.
This is highlighted in the current study by George and colleagues who demonstrated that, at a large rheumatology practice network, many patients were not able to access their routine care. They also showed that the patients that were most impacted were older, Black, Hispanic, of low socioeconomic status and lived in rural areas. Offering telemedicine visits to patients did help to minimize some of the disruptions. This practice network continues to provide telemedicine visits to approximately 25% of all follow up visits.
As rheumatologists, and indeed as health care providers, it is time for us to take bold steps to assure that the quality of care we would demand for ourselves is indeed available to all of our patients. Telemedicine allows us to continue to do just that. Barriers do exist, but these should not be a virtual roadblock for our patients to continue to receive high, quality care for their disorders.
Perspective
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The rheumatology care and rise in telehealth response during COVID-19 in community-based practices by George and colleagues, is a very useful study. In my practice with 16 rheumatologists and myself, along with 6 offices in New Jersey, right between Philadelphia and New York, we felt the impact hard and fast.
Telehealth made it possible to assess whether or not to change a patient from an infusion to an oral or injection so treatment was not missed, and the risk of contracting the virus by an unnecessary ER visit was less likely to happen. Assessment of the need for joint injection could be made over the phone or video and the patient could avoid a visit if not necessary; at other times, a house call was made.
Even osteoporosis fracture risk reduction efforts were able to be maintained throughout this, by keeping in touch with patients by video phone call. If the risk was too great to the office, then the injection could be administered car side or during a house call.
We did learn from this study that more needs to be done to improve access for low-income families and people of color. Perhaps the benefits that patients received by staying on their medications and treatment plans during the pandemic due to telehealth should be studied closer to find the cumulative benefits from this service. If we could prove the benefits can save health care dollars in the long term, then money will be put toward helping with access.
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